Perspectives 71 MJA 200 (2) · 3 February 2014 The Medical Journal of Australia ISSN: 0025- 729X 3 February 2014 200 2 71-72 ©The Medical Journal of Australia 2014 www.mja.com.au Perspective lcohol is one of the most widely used drugs in Australia. 1 In 1988, the World Health Organization International Agency for Research on Cancer declared it a Group 1 carcinogen — a fact of which few Australians are aware. 2 In Australia annually, over 2000 cancer diagnoses and around 1400 cancer deaths are attributable to long-term alcohol use. 2 Recent evidence indicates that any alcohol consumption increases the risk of developing cancer, including for the common cancers such as those of the bowel and breast, while smoking and alcohol together have synergistic effects that exceed the risk from either individually. 2 This evidence has changed the known risk of developing cancer for a significant number of Australians, particularly those drinking alcohol at light-to-moderate levels, as risk increases cumulatively with consumption over time. 2 Most of the Australian population of light-to-moderate drinkers who adhere to the National Health and Medical Research Council (NHMRC) guidelines of no more than two standard drinks daily 3 may thus unwittingly be putting themselves at increased risk of developing cancer from their low-level chronic exposure to alcohol. Unlike genetic predisposition or increasing age, alcohol consumption is a modifiable risk factor for cancer, and, therefore, a legitimate target for public health intervention. Conveying this new message to the Australian community is a major public health challenge, but is necessary to educate and inform the community about the long-term alcohol- related risks of cancer, and ultimately, to modify the risk of this serious consequence of regular light-to-moderate alcohol consumption. Several strategies have been suggested as part of this initiative, including volumetric taxation of alcohol and restrictions on alcohol marketing and promotion. 2,4 As part of a comprehensive alcohol-control strategy, one approach deemed to be cost-effective, with high levels of public and political support, is the introduction of mandated health warning labels that include information about the alcohol- related risk of cancer on alcohol bottles and containers. 4 Additional measures (such as messages displayed on posters, coasters, or other promotional material at the point of sale) may be required to ensure that the proposed health warning messages reach consumers purchasing alcohol in glasses in hotels, clubs, or bars. 5 However, a number of issues need to be addressed to clearly establish the acceptability and efficacy of mandated alcohol labelling. First, any policy mandating alcohol warning labels involves state interference with a third party (alcohol producers), with the aim of changing individuals’ preferences and behaviours, which could be deemed paternalistic, 6 embodying a “nanny state” approach. Notwithstanding that alcohol is addictive and intoxicating, such policies are controversial. 4 Moreover, it may be difficult to argue that those drinking at light-to- moderate levels are sufficiently compromised, or indeed, sufficiently problematic, to justify intervention. One of the arguments supporting policies that may be deemed paternalistic is that such policies counter “our cognitive limitations, bounded rationality and weakness of will”; 7 when faced with temptation, it is all too easy to reverse long-term rationally derived preferences. So, it may be that alcohol consumption is often not a matter of informed autonomous choice, but reflects an immediate prioritisation of short-term gratification over potential future reward. From this perspective, warning labels may be seen as supporting rational choice, and thus promoting autonomy. Regardless, few would deny that consumers have the right to know the health risks associated with the products they consume. Second, alcohol plays a significant role in the social fabric of Australian culture, providing economic benefit, enhancing social interactions, and featuring in various cultural activities and traditions. For example, sport (a highly valued activity) is fundamentally linked with the advertising and promotion of alcohol, both at the individual and corporate level. 8 The alcohol industry contributes substantially to the Australian economy, through tourism, employment in pubs, clubs and bars, and through sales locally and overseas. Consequently, moves to encourage a reduction in alcohol consumption seem likely to meet with resistance from various sectors of the Australian community including from the alcohol industry itself. This industry has, in fact, argued for self-regulation of the provision of information about alcohol risks through warning labels. Public health agencies, however, point to evidence showing that previous attempts to self-regulate have proven inadequate, and call for mandatory government regulation to ensure consistent implementation of alcohol warning labelling and to enforce compliance. 9 Thus, for example, voluntary labelling proposed in mid 2011 by the alcohol-industry- funded organisation DrinkWise was promptly rejected as inappropriate and ineffective by the then Alcohol Education and Rehabilitation Foundation, which then released its preferred versions. 9 It should also be acknowledged that plans to mandate alcohol warning labelling will be subject to legislation affecting trade and investment. Some public health advocates have voiced concern that current proposed negotiations (the Trans- Pacific Partnership Agreement) may hinder the development and implementation of effective warning labels. 10 Third, it is unclear how effective alcohol labelling will be in modifying behaviour to reduce the risk of harm. There is Alcohol and cancer: the urgent need for a new message A Jaklin A Eliott PhD, BA(Hons), Senior Lecturer and Social Scientist Emma R Miller PhD, MPH, Senior Lecturer and Epidemiologist Discipline of General Practice, School of Population Health, University of Adelaide, Adelaide, SA. jaklin.eliott@ adelaide.edu.au doi: 10.5694/mja13.10426 New knowledge on old bottles: alcohol labelling and an unpalatable message “ Recent evidence indicates that any alcohol consumption increases the risk of developing cancer ”